Liu et al. BMC Health Services Research (2018) 18:961 https://doi.org/10.1186/s12913-018-3783-5 RESEARCHARTICLE Open Access Differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control in China: a multicenter study Chun Liu1†, Shaoyong Xu1†, Jie Ming1†, Aihua Jia1,2, Yingji Wei3, Hui Li4, Yang Jiao5, Mingxi Song6, Yadong Zhao7, Yafang Du8, Wenjuan Yang9, Xiaoqiang Lu10, Shengqi Shi11, Hui Tong2, Guangtang Jia12, Guohua Zhao13, Li Wang14, Mei Zhang15, Junlin Wang16, Wenshu Liu17, Lin Fang18, Fuhong Dong19 and Qiuhe Ji1* Abstract Background: To investigate the potential barriers to optimal diabetes control by evaluating the different perspectives of physicians and patients on such matters in China. Methods: This multi-center survey was conducted from December 2015 to March 2016. A multi-stage stratified random sampling method was used to sample representative diabetes physicians and patients in 18 hospitals in Shaanxi province, China. A self-designed questionnaire was used. The questionnaire mainly consisted of 2 questions for physicians and 1 question for patients of which the participants were required to rank in priority of 3 (for physicians) and 2 (for patients) choices from a list of barriers. The strategies to improve diabetes control were only in the questionnaire for physicians. Results: A total of 85 physicians and 584 patients completed the questionnaire. Physicians and patients differed regarding the patients’ awareness of the risk of diabetes: over 70% of the physicians believed that the patients had no sufficient understanding of the harm and risk of diabetes, whereas the patients believed otherwise. Both physicians and patients considered self-monitoring of blood glucose to be an important link of glucose control; unfortunately, most of the patients failed to do so in practice. In addition, physicians considered “improving health insurance coverage for diabetes” as the first important measure and “providing more and easy-to-use diabetes brochures or educational materials for patients” as the second important measure to improve diabetes control. Conclusion: The survey revealed differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control. The main potential barriers to optimal diabetes control were patient’s poor lifestyle interventions, limited understanding of the danger of diabetes, and poor self-monitoring of blood glucose. From the physicians’ perspective, China’s primary focus about diabetes control in the future should still be put on diabetes education, particular the importance of lifestyle interventions. Keywords: Diabetes control, Barriers, Cross-sectional study, China * Correspondence: [email protected] †Chun Liu, Shaoyong Xu and Jie Ming contributed equally to this work. 1Department of Endocrinology, Xijing Hospital, Air Force Medical University, 169 Changle Road West, Xi’an 710032, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liu et al. BMC Health Services Research (2018) 18:961 Page 2 of 8 Background level city (Yulin, annual Gross National Products GDP > Diabetes prevalence has been increasing dramatically in 50,000 yuan per capita), a moderately developed China in recent years. In 2010, the prevalence rate was prefecture-level city (Baoji, annual GDP 30,000–50,000 11.6% for diabetes and 50.1% for pre-diabetes in adults yuan per capita), and a developing prefecture-level city over 18 in China; the crude prevalence rate was 9.5% for (Ankang, annual GDP < 30,000 yuan per capita) were sam- diabetes and 35.5% for pre-diabetes in Shaanxi province; pled; the GDP was classified according to the 2015 GDP currently, the diabetic patient population in China in Shaanxi Province. This step was non-randomized. Step accounts for approximately one-fourth of the diabetic pa- 2 involved stratifying the hospitals in the capital city and tients worldwide [1]. With the rise in the overall incidence the three prefecture-level cities. The hospitals in the cap- of diabetes and the incidence of diabetes in younger popu- ital city were stratified into medical university hospitals, lations in China, individuals and the society are facing a tertiary municipal hospitals, and secondary county hospi- higher burden of diabetes treatment. Unfortunately, even tals; the hospitals in the prefecture-level cities were strati- with continued innovation in anti-diabetic drugs and con- fied into tertiary municipal hospitals and secondary stantly evolving ideas regarding diabetic treatment, a sub- county hospitals. Step 3 involved sampling the hospitals. stantial increase in expenses for diabetes care has failed to Given the differences in the city sizes and the distribution significantly improve the diabetes control rate; conversely, of medical resources between the capital city and the the morbidity of diabetes has increased each year [2]. prefecture-level cities, we used a simple random sampling Therefore, it is important to investigate the potential bar- (drawing) method to randomly sample three medical uni- riers to optimal diabetes control. versity hospitals, three tertiary municipal hospitals, and Diabetes physicians have gained rich experience in the three secondary county hospitals in the capital city in daily diagnosis and treatment of diabetes, and therefore, addition to one tertiary municipal hospital and two sec- their feedback on the potential barriers to optimal dia- ondary county hospitals in each of the prefecture-level cit- betes control is extremely valuable. Numerous Chinese ies. Thus, we sampled a total of 18 hospitals, including and foreign studies have shown that from the perspec- three medical university hospitals, six tertiary municipal tive of physicians, the patient’s lifestyle [3, 4], mental hospitals, and nine secondary county hospitals. Step 4 in- health [5], economic status [6], and religion [7] have a volved sampling the physicians. According to the distribu- significant effect on diabetes control; furthermore, the tion of physicians in the different levels of the hospitals, physician’s vocational education [8], specialist nurses [9], we randomly sampled six residents, three attending physi- and education [10] also play important roles in diabetes cians, and one chief physician from each medical univer- control. However, the opinions differ between physicians sity hospital; three residents, two attending physicians, in different surveys [3–6]. Notably, few such studies in and one chief physician from each tertiary municipal hos- the past have investigated the potential barriers to opti- pital; and two residents and one attending or chief phys- mal diabetes control from the perspective of patients; ician from each secondary county hospital. Thus, we consequently, an understanding of different perspectives sampled a total of 93 physicians, including 54 residents, between physicians and patients will, undoubtedly, pro- 21 to 31 attending physicians, and nine to 19 chief physi- vide an important reference for improving diabetes con- cians. Step 5 involved sampling the patients. We used the trol and patient compliance in the future. cluster random sampling method and enrolled all of the As such, this multi-center study was designed to inves- patients with type 2 diabetes (based on World Health tigate the potential barriers to optimal diabetes control Organization 1999 criteria) who were hospitalized for dia- by evaluating the different perspectives of physicians and betes treatment in department of endocrine during a cer- patients on such matters, and also investigate the tain time window and who met all of the study criteria, physician-recommended public health measures for im- had poor diabetes control (HbA1c ≥ 7%), and were willing proving diabetes control in China. to participate in this study, until the planned number of participants was reached. Given the difference in ward Methods capacity between the different levels of hospitals, we Study design planned to sample 40 patients in each medical university This multi-center cross-sectional survey was conducted hospital and tertiary municipal hospital and 30 patients in from December 2015 to March 2016. A multi-stage each secondary county hospital, for a total of 630 patients, stratified random sampling method was used to sample which provided a sufficient sample according to previous representative diabetes physicians and patients in literatures [11–23]. Shaanxi province, China for this survey (Fig. 1). Step 1 involved sampling physicians and patients in Data collection the cities. In addition to the capital city (Xi’an), physicians We developed our own questionnaire for data collection. and patients from an economically developed prefecture- While designing the questionnaire, we referred all the Liu et al. BMC Health Services Research (2018) 18:961 Page 3 of 8 Fig. 1 Protocol design flowchart. *: numbers in each